Minibus Driver Application Form

Driver Number (leave blank )
Group
Name
Address
Tel No
Date of Birth
Occupation
Gender	Male/Female
Driving Convictions	YES / NO (if yes please complete table 1 below)
Claims	YES / NO – (if yes, please complete table 2 below)
Special Terms	YES / NO (if yes please complete table 3 below)
Type of licence
Theft/Dishonesty Convictions

Table 1 - lease list below any driving convictions on your licence

Conv. No.	Conv. Date	Conviction Code	Fine	Disqualification Period	Connected To Claim No.
1
2
3

Table 2 - Please list below any Claims made within the last 3 years

Claim No.	Claim Date	Incident Type	Value	Fault Yes/No	NCD Affected	Vehicle registration
1
2
3

Table 3 - Please list below any relevant medical conditions

Cond. No	Description	Medication	DVLC Notified	Licence Restricted
1
2

I confirm the above details are correct and agree to abide by the rules as laid out in the attached ‘Instructions For Use’ document. I also agree that any changes in details listed above will be notified to the Minibus Convenor immediately. Note – Failure to do this will result in you not being insured to drive this minibus.

Signed………………………………………………. Date:……………………….